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Framework for Research on Implementation of Process Redesigns

Ashok, Mahima, PhD, MS; Hung, Dorothy, PhD, MA, MPH; Rojas-Smith, Lucia, DrPH; Halpern, Michael, T., MD, PhD, MPH; Harrison, Michael, PhD

Quality Management in Health Care: January/March 2018 - Volume 27 - Issue 1 - p 17–23
doi: 10.1097/QMH.0000000000000158
Original Articles

Background: Complex system interventions benefit from close attention to factors affecting implementation and resultant outcomes. This article describes a framework for examining these factors in process redesign (PR) and for assessing PR outcomes.

Methods: Using literature scans and expert comment on draft frameworks based on the Consolidated Framework for Implementation Research, a team of researchers developed the PR framework for the Agency for Healthcare Research and Quality. As a case study, an independent team of researchers in a large care system subsequently applied the PR framework to implementation of Lean-based primary care redesigns.

Results: The PR framework adds 2 domains to the Consolidated Framework for Implementation Research, focused on relevant measures of implementation and outcomes, as well as some new constructs to the Consolidated Framework for Implementation Research. Using the PR framework to guide a study of primary care PR, researchers found that the health care reform environment encouraged staff recognition of need for redesign, but physicians worried about key redesign issues, including colocation with care team partners and the competencies of the individuals assigned to manage new workflows. Team member acceptance of the redesign was also influenced by other features of the implementation process and contextual features, including the decision style of the local clinic.

Conclusions: The PR framework helped guide the qualitative study and aided researchers in informing their leadership about critical issues affecting PR implementation.

Public Health Research Division, RTI International, Washington, District of Columbia (Drs Ashok, Rojas-Smith, and Halpern); Palo Alto Medical Foundation Research Institute (PAMFRI), Palo Alto, California (Dr Hung); Health Services Administration and Policy, Temple University College of Public Health, Philadelphia, Pennsylvania (Dr Halpern); and Center for Delivery, Organization, and Markets, Agency for Healthcare Research and Quality, Rockville, Maryland (Dr Harrison).

Correspondence: Mahima Ashok, PhD, MS, Public Health Research Division, RTI International, 701 13th St, NW, Ste 750, Washington, DC 20005 (

The authors acknowledge the support of Christine Chang, MD, MPH, from the Agency for Healthcare Research and Quality (AHRQ) and Ms Laura Small from RTI International.

Development of the framework was supported by funding from the AHRQ, US Department of Health & Human Services (contract no. HHSA-290-2007-10056I). The case study in this paper resulted from research funded by the Agency for Healthcare Research and Quality under its ACTION II contract HHSA2902010000221, Task Order 2. Funding support for manuscript preparation was provided by RTI International. All statements expressed in this work are those of the authors and should not in any way be construed as official opinions or positions of AHRQ or the US Department of Health & Human Services.

The authors declare no conflicts of interest.

© 2018Wolters Kluwer Health | Lippincott Williams & Wilkins